MEDICARE: SAMANTHA JANE BRODERS LGSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker	29954	MN

General Provider Information

NPI Number	:	1215865795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA JANE BRODERS LGSW

Provider Business Mailing Address
First Line	:	1350 W 106TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55431-4126
Country	:	US
Telephone Number	:	952-806-7049
Fax Number	:

Provider Business Practice Location Address
First Line	:	9501 TOLEDO AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55437-2052
Country	:	US
Telephone Number	:	952-806-7049
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/13/2026
Last Update Date	:	05/14/2026

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